He is unconscious, barely breathing, lying on a sidewalk in downtown vancouverWhen the firefighters arrive, a passerby explains that the man has suffered an overdose of fentanyla powerful synthetic opioid. While one firefighter pumps oxygen into the victim’s mouth, another injects him with naloxone, which reverses the chemical effect of opioids. The first injection does nothing; a second is administered. The man sits up and staggers to his feet. He refuses all offers of help and staggers away down the street. The firefighters can only watch him go.
Blessed with stunning scenery, a temperate climate and low crime, Vancouver often tops lists of the world’s most liveable cities. For years, along with the British Columbia provincial government, it has pioneered a program to curb drug-related deaths known as harm reduction. The health authorities began to distribute clean needles to late 1980s and later added free crack pipes. In 2003, the Vancouver International Airport opened North America’s first supervised injection center. In the mid-2000s, the city launched a prescription heroin testing program (in addition to others offering lower-strength methadone). In the following years, HIV and hepatitis C infections decreased. The number of drug-induced deaths fell from a record 400 in 1998 to 183 in 2008. Harm reduction seemed a success.
Then fentanyl arrived. Fifty times more powerful than heroin, easy to manufacture and cheap, this synthetic opioid has flooded North America in recent years. “You can’t even find heroin on the streets anymore,” says Brittany Graham, director of the Vancouver Area Network of Drug Users, an advocacy group. Other synthetics are often mixed with street drugs, such as benzodiazepines, especially dangerous sedatives combined with fentanyl.
In 2012, fentanyl was implicated in only 5% of overdose deaths. In 2023 that figure was 85%. The annual body count has increased tenfold in the same period. The rate of fatal overdose In British Columbia, the rate is more than double Canada’s overall rate and six times higher than in England and Wales (though still lower than in the worst-affected areas of the United States). Overdoses are now the leading cause of death among Britons aged 10 to 59, claiming more lives each year than murder, suicide, accidents and natural diseases combined.
The drug problem is most acute in Vancouver’s Downtown East Side, several astonishingly squalid blocks jutting out from the city’s affluent core. On any given afternoon, the area’s main street is filled with people sitting, slumped or sprawled on the sidewalk amid a jumble of makeshift shelters. Many openly inhale smoke from glass pipes or pieces of aluminum foil. Smoking opiates is now more common than injecting them, but used needles are still strewn about. Most of the 50 or so calls the neighborhood’s firefighters respond to a day are drug-related. The East Side’s fatal overdose rate is a dozen times the provincial average.
But it’s far from the only place where deaths occur. Most happen indoors. “We go all over the city,” a fire department spokesman says. “We go into mansions and penthouses. It’s in every community and every age group.” Often, the victims aren’t hardened addicts, but unsuspecting partygoers who took something far more potent than expected. It’s an easy mistake, especially with counterfeit pharmaceutical pills laced with fentanyl circulating.
The plague is not limited to cities either. Overdose rates have skyrocketed across the province. The mountain town of Hope (population 7,000), a two-hour drive northwest of Vancouver, has the highest overdose rate in the province. Rural health authorities blame the lack of services on the supply of harmful drugs.
Overwhelmed by the fentanyl assault, authorities have redoubled harm reduction measures. Since 2020, medical professionals have been licensed to supply thousands of addicts for free high-strength prescription opioids, in the hope that this will keep them away from unpredictable street drugs. The pills are mostly hydromorphone, a commonly used painkiller, but some heavy users insist on pharmaceutical fentanyl. Most controversially, last year BC became the only province in Canada to decriminalize possession of small amounts of all drugs of abuse: methamphetamine, cocaine, heroin, fentanyl and many more.
But deaths have risen anyway, testing arguments for harm reduction and raising political risks for Justin Trudeau, the Prime Minister, and other politicians who have supported her. It’s still too early to declare the policy a failure: There are many factors behind the recent rise in overdose deaths, including the Covid-19 pandemic, which left many drug users dangerously isolated. Renewed harm reduction policies have not yet been in place long enough to generate data that provides clarity on whether they are working against fentanyl.
There are some encouraging signs. A recent study found that addicts who take prescription opioids are at lower risk of overdosing. And after years of steady increases, overdoses may finally be trending downward: the death rate in the first four months of this year is lower than in the same period in any of the previous three years.
Harm reduction has sparked a backlash. Pierre Poilievre, leader of Canada’s conservative opposition party, calls Trudeau a “crazy” for approving decriminalization. He wants to end federal funding of prescribing opioids to addicts. In May, the Trudeau government rejected a request from Toronto to decriminalize drug possession in the city. BC is feeling the pressure: in May it reinstated rules against public drug use. (In the United States, Oregon has completely reversed its decriminalization policy.)
Few are calling for a return to the policy of putting petty offenders in jail, but critics say the province should put less emphasis on harm reduction and more on efforts to get people to stop using drugs altogether. Some even suggest forced treatment. For many addicts, however, a lack of affordable housing, treatment beds and mental health care makes recovery nearly impossible. “Naloxone can help prevent someone from dying today, but it can’t solve all these other problems,” says Paxton Bach, a leading addiction doctor.
Harm reduction alone can do no more than its name suggests. It appears to help reduce the body count, but it alone cannot cure all the damage caused by drugs as potent as fentanyl and other synthetics. “The drug supply is changing under our feet. It’s not like a virus mutating, but a completely new disease,” says Bohdan Nosyk, an addiction researcher. The disease will need new treatments.
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